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People age 65 years and older account for 40 percent of inpatient operations and one-third of outpatient procedures, and these older patients are more vulnerable to longer hospital stays and other complications after surgery than younger patients. A beta test of a program for older adults who undergo major surgery has resulted in shorter hospital stays and lower rates of post-surgery delirium, among other improved outcomes, according to research presented at the virtual American College of Surgeons (ACS) Clinical Congress 2020.
The Aging Veterans Surgical Wellness (AVSW) program at the Rocky Mountain Regional Veterans Affairs Medical Center in Aurora, Colorado, served as a beta testing site for the American College of Surgeons Geriatric Surgery Verification program (ACS GSV). The study involved 186 patients, 158 of whom were matched according to age and type of operation to a comparative control group of 308 patients from the national Veterans Affairs Surgical Quality Improvement Program (VASQIP) database.
“When we looked at the matched cohort from the VASQIP data base, we found a decreased hospital length of stay of four days compared to five days, which is very significant,” said Alexandra Kovar, MD, a general surgery resident at the University of Colorado School of Medicine and chief resident for quality and safety at the Rocky Mountain Regional VA Medical Center.
“When we compared our outcomes to those reported in previously published research, two important postoperative outcomes in our patient population showed significant improvement: development of postoperative delirium and functional health postoperatively.”
The rate of post-surgery delirium in the AVSW population was 9.3 percent compared with 12.1 percent reported in the ACS National Surgical Quality Improvement Program Geriatric Surgery Pilot study. Likewise, only 19.1 percent of the AVSW patients reported functional cognitive decline after their operations compared with 42.9 percent in the pilot study. “These variables are specifically important to older adults because the development of postoperative delirium can affect their cognition long term,” Dr. Kovar said. “Functional health is related to independence, mobility, and overall quality of life.”
The ACS GSV program was introduced July 2019. It sets forth 32 different surgical standards that hospitals can use for a multidisciplinary team approach to optimize surgical care for older adults facing surgery. The standards address the preoperative work-up, postoperative management, care transition, data collection, quality improvement, professional and community outreach, and research.
Senior study author Thomas Nichols Robinson, MD, FACS, chief of surgery at Rocky Mountain Regional VA Medical Center and a member of the ACS GSV program panel, noted that the standards can be implemented at any hospital. “The majority of these standards are aimed at the clinical processes necessary to optimize the surgical care of older adults, but the standards also address the administrative support needed to improve the surgical care of older adults, and measurement outcomes necessary to improve the care of older adults in your hospital,” he said.
Dr. Kovar noted two interventions were important to the success of the AVSW program. “The implementation of the preoperative multidisciplinary conference where we talk about the patients prior to having surgery,” she said. “We discuss their needs in the three phases of care, for example, whether they’re going to need physical therapy, occupational therapy, or a nutritional consult. We get them teed up for surgery so when they arrive they’re ready to go. The second intervention is the daily inpatient rounding team, who assesses the patient on a daily basis.”
In the next step for their research, Dr. Kovar and colleagues aim to enroll more patients and include more specific internal and external cohorts to evaluate more postoperative outcomes, including 30-day post-surgery death and complications. Future variables would include patient-reported outcomes and outcomes using telehealth, she said.
Added Dr. Robinson, “Surgeons intuitively recognize that the group at highest risk of poor outcomes are older adults; the frail older adult is at highest risk for longer hospital stays, complications, and needing to go to institutions after discharge. This program directly addresses those needs unique to frail older adults to try to prevent poor outcomes after surgery.”
“The results of this beta pilot show how well the Geriatric Surgery Verification program works in a hospital that puts forth the institutional commitment to improve the care of older adults facing surgery. Identifying and addressing potential vulnerabilities specific to the geriatric surgical patient such as delirium, result in better patient outcomes. And a reduced hospital stay is not only a good outcome for patients, it also indicates a more efficient use of resources,” said Clifford Y. Ko, MD, MSHS, FACS, principal investigator for the ACS Geriatric Surgery Verification program, who was not involved with the study.
American College of Surgeons